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36th NACDA Convention
Salt Lake City, Utah
June 10-13, 2001

NCAA Division II Breakout Session
NATA/Athletics Training Issues
Tuesday, June 12, 10:00 - 10:50 a.m.

Bill Fusco

I'm Bill Fusco, director of athletics at Sonoma State University and a member of NACDA's Executive Committee. Before we begin, we would like to recognize Southwest Recreational Industries, who is our audio-visual sponsor. Our session this morning in entitled NATA/Athletics Training Issues. Speaking will be Randy Dick, assistant director of health and safety at the NCAA; Dennis Miller, head athletics trainer at Purdue University; and Chad Starkey, chair of the Educational Council at NATA. To let you know, we were hoping to have a power point set up and it's not here so we may stop and get that set up quickly to facilitate the presentation.

Before we start, I would like to comment that this is an issue that really has taken a prominent position at my institution. With all of the changes that are taking place, such as nontraditional playing seasons, these issues are creating a number of concerns from a risk management point of view and a budget point of view. We have an outstanding panel this morning. At this time, I would like to bring up Chad Starkey.

Chad Starkey

Good morning. My voice, which is funky anyway, is still on Eastern Time. Deal with me please. I do have a power point presentation I would like to share with you. I would like to start out by giving you some background. I'd like to tell you a little bit about the history about what was going on with education in athletics training, sort of how we got here and why we got here.

In 1997, the National Athletics trainers Association concluded a four-year process where we evaluated what it took to become an entry-level athletics trainer. From our perspective in this room, the most relevant of these is that effective January 1, 2004, to be eligible to sit for the NATA/BOC Certification examination, which is required for state licensing, students must be a graduate of an accredited program. Right now, we have a dual route to entry where a student can elect to go to an accredited program or enter into an internship in an unaccredited program.

We did this for several reasons, but one of the two biggest reasons was for professional advancement. The roles and duties in workplaces of athletics trainers are expanding and we need to respond to that. Secondly, and just as importantly, we're striving to provide the best health care for athletes that's possible. To achieve those goals, we had to do something different.

Between the time of the announcement of the single route to certification and the implementation of it is seven years. The first time we had something in the NCAA News about this was about two years ago. This has been an issue that's been on the table for a while. Part of my job is helping you all deal with it.

What effect will it have on schools that do not elect to have an accredited program? The most important thing you can take away from my portion of this presentation is that students can still be involved in the delivery of athletics training services. The big difference to that individual is that he or she would then have to go on to an entry-level master's degree level to be eligible to sit for the exam.

I have a feeling that when 2004 rolls around, the impact that we're going to see from this isn't as great as we anticipated. Approximately 85 percent of the students who enter into an internship never sit for the exam anyway. Of those individuals that do, significantly less than half of them ever pass the exam through this route. We found that the primarily reason students get involved this way is that they want to be involved with college athletics, especially if there's work study involved, and they have a choice between working with athletics and filing books in the library. They will always go for the athletics assignment.

There is a chance though, that these roles may change. By the time I'm done with this, we may see that the way that we've used students in athletics health care over the past several years has been inappropriate and maybe outside of many of your state practice acts.

We can look at athletics health care as being provided by three different groups of individuals. First of these are licensed health care providers, which would be athletics trainers, physicians, physical therapists, EMTs, etc. The second is students. By students, I mean individuals who are engaged in a formal course of study to be an athletics trainer. Lastly, first responders.

What each of these individuals can do varies greatly from state to state. That is dictated by state practice acts. State practice acts are ultimately designed to protect the public. In our case, the public are those athletes who we're providing services to. It tells us what professions can do and what professions can't do. It also defines what students can and can't do and the level of supervision involved in this.

Rather than tell you those 41 states that do have practice acts, there are nine states that do not have practice acts. If you currently working in one of these states, much of what I have to say to you today isn't going to mean a whole lot to you, but the role of students and athletics trainers themselves can be infringed upon by other acts within the state. If you have a risk manager university attorney, that is always the best source to get this kind of information from.

Athletics training students are those individuals who are engaged in a professional course of preparation. As I said before, effective January 1, 2004, to be eligible to sit for the exam, there will only be the accredited program option.

Students, when practicing athletics training in delivering athletics training services, must be directly supervised by a certified and licensed professional. This is something that is in effect now. It has been in effect since 1972. Basically, what we're saying is that students can't go out and be little ATCs. These individuals can't make diagnosis, they can't make return to play decisions without some type of intervention or supervision there.

Unsupervised students should be considered first responders. First responders can be students or coaches; they can be the work study student we spoke about before. They should have current first aid CPR certification. To protect not only the student, but also the institution, there should be a written job description. There should be a standard protocol for injury management. This all ties into the emergency medical plan that Randy will talk about. For the most part, at least from a student standpoint, the job description of a first responder when an injury does occur is to stabilize, render immediate assistance and someone's help.

What other options are available for institutions that do not have an accredited program? To me, one of the fundamental things that can be done is to require all individuals who are associated with college athletics to be first aid and CPR certified. Coaches, managers, grounds people, are all in a position where significant injury is likely to occur. We know the one thing tied with college athletics is that the men and women who participate in them are at a risk for injury.

Other institutions can affiliate with an accredited athletics training program. I work in Boston and we have affiliations with several schools in and around the Boston area where our students, for part of their authentic affiliation, will go out be assigned to some of the other institutions. Changes in accreditation standards have made this more flexible. If I now wanted to send an individual to Kansas, that is now permissible, where, up until the very recent point in time, it had to be in an immediate geographic proximity.

A word of advice, seeking an accredited athletics training program, more times than not, isn't going to be a viable option. To do this, it is expensive financially and in terms of time commitment. If an institution can't afford to start an accredited program, there's probably a financial pool there to hire you all of the help you need to provide this coverage.

What I've just given you is the Reader's Digest condensed version of information you can find on the web at www.cool.com\ncaa. You can also link to this site from the NCAA site. This has probably 40 or 50 pages of documents and recommendations for you. Thank you.

Randy Dick

Randy Dick from the NCAA. I just want to carry on with what Chad talked about. The first thing I'll start with is in the NCAA constitution. The words say, "It is the responsibility of each NCAA institution to protect the health and provide a safe environment for each of its individual student-athletes." It is the responsibility that we all have, whether it's at the national office or at your institution. It's pretty well spelled out in the constitution that is in our manual.

I want to give you a little brief history of the NCAA perspective of this issue. We started with a survey that we did across all three divisions in 1998, trying to look at what the current coverage issues were in college athletics. The results of that survey really got the competitive safeguards committee, which I'm the liaison to, interested in this topic even more so than they have been in the past. That showed that in all three divisions, there was pretty good coverage during the regular season for some of the high profile sports like football and basketball. However, sports like track and field and cross country showed not the optimal coverage. When we started getting into the out of season nontraditional practices and strength and conditioning, we really saw significant drop offs in terms of the coverage. Anybody available could qualify to render emergency care. The lack of that was almost, in many cases, less than 50 percent of the schools. That raised one red flag with us.

The NCAA Executive Committee, in 1999, primarily through the stimulus of the Division II Management Council wanted the Competitive Safeguards Committee to develop some information in terms of what Chad just talked about, the potential impact of this educational reform with NATA on the health care coverage issues. Independently, we had done the survey and showed that the current coverage was an optimum. We also had this NATA reform, which might be some issues we needed to be educated on.

From that, we spent almost a year putting together a document that I hope most of you have seen. It physically came to athletics directors of every NCAA institution last November. It also exists on our web site. It was put together with the assistance from NATA, significant assistance. As Chad said, we have linked web sites, with lots of information on this issue. I encourage you to go there if there are specifics that you need to pull away from.

The main point I will re-emphasize with Chad, is coming up with options for schools to deal with this issue. Before I get into specific options, I'll repeat a little of what Chad said. One of the things we have to hand out afterwards is a checklist with suggested ideas when you're evaluating your health care and coverage at your institution. This was handed out at the convention this year. If you weren't there, we have them here that you can pick up. I won't go through the whole thing, but I'd like to talk about a few of them.

One of the first and most important things is, when you're assessing your health care coverage, you need to identify every activity that falls within the responsibility of the athletics department of which you are responsible for coverage. That includes in season and out of season opportunities, strength and conditioning sessions and individual skill sessions. Every one of those pieces has to be fit into your equation. You are responsible, it's a formal activity and it's the responsibility of the athletics department to be sure there's the appropriate coverage there.

Another very important piece is establishing an emergency plan for every one of these activities. On our web site is a template of an emergency plan that was contributed by the University of Georgia. Many of you may not be able to do everything the University of Georgia can do, but it is a template with just general things you might want to think about. If you do not have this in place, it's a great place to go for a resource to begin to structure your own. For every one of these activities you at least need to have access to 911 or have a cell phone with the coach, something so there is evidence of a consideration of the emergency plan.

Another issue you talked a little bit about yesterday is the out of season practices and games. You need to identify, when you're voting on legislation or considering legislation, the additional resources that are going to be necessary for any expansion of playing or practice seasons in season or out of season. For a long time, we've expanded the playing and practice seasons for our athletes and there are a lot of positives with that. But, there is a cost to that and a cost, for many cases, hasn't been considered. Somebody has to provide the coverage, somebody has to provide the taped ankles, the rehab for people who get injured during these out of season opportunities, at the same time as the current in season opportunities are going on. That is something that hasn't been done all the way across the board in the past. As you, in the future, go forward, assess your own institution's ability to be able to address these expanded practice and playing seasons.

You also should work with your athletics staff, your medical staff, to identify and plan for the components of coverage that are outside of the practice field. You want a physical person or some plan for every organized practice or game, but there is also a time commitment going on in rehabbing athletes and taping athletes and getting them prepared for each of these activities. Again, there's an awareness factor that needs to be factored into the equation when you're trying to evaluate the resources you need.

Consider some of the options. Chad has outlined them very well. On our web site, and as part of this document that we distributed to our member institutions, we have specific examples of schools who are doing a lot of things. As we were trying to get information to the membership, we felt the best way to do this was to contact schools that were doing these different options. They allowed us to put their phone numbers and contact people in there so that you, who needed to be assessing this, could go right to the source and figure out what the pros and cons of each of them are. This information is on our web site.

Let me go through these options again. Seeking accreditation, which Chad mentioned is a possibility, the athletics training clinical site partnership, in other words, not having an accredited program for this, but using a school's resources that do have an accredited program. Physical therapy clinic affiliation. There are a couple of schools in Division I and III that are doing that, increasing, the number of certified staff and the rationale of how that goes on. The use of student assistants as first responders is another option Chad mentioned. We put this graph together telling you what their situations are with a phone number, contact people, so if you need more specifics on these options, it's a great place to go.

We are trying to continually assess this situation. The bottom line is, we've asked that for each organized practice and game, you need to have somebody delegated that is qualified to render emergency care. Maybe that is teaching the coach CPR, maybe it's an athletics trainer, or access to 911 through your emergency plan, but those things identify everything you are responsible for. You have to come up with a first step. It may end up being costly, but you need to do this.

Lastly, another piece of this is, try to establish a mechanism for risk assessment by sport or activity so that you can come up with some kind of resource allocation. Realistically, you're not going to have the optimal resource for every practice and game, but if you've got three or four things going on, it may be helpful for you to know what potential activity might be at highest risk. The NCAA's entry surveillance system which currently exists is one opportunity and able to do that. We're trying to enhance it by making it an electronic system over the next few years so that you'll have a lot easier access to that data. We will also expand it to a lot more sports.

NATA has also come up with some information that can help you in terms of trying to come up and allocate your resources. Denny will talk about that.

Denny Miller

We can send our astronauts from Purdue up to the moon, but we don't do real well with the power point. A couple of years ago, I was asked to chair a task force that was entitled Appropriate Medical Care for Intercollegiate Athletics. This was a response from our membership. With increasing number of sports, they are being asked to cover an increasing number of athletes, practices, non-traditional settings, etc., so we set out to do that. We came up with about a 60-page document for this. We introduced it to the National Athletics trainers Association Board of Directors a year ago, after having had a group of our athletics trainers, plus doctors and other parties join in with us to look at the entire situation.

In February 1998, our task force was created. The mission was to establish guidelines for appropriate medical care in order to supply the best possible health care for all student-athletes without discrimination, to address the student-athlete welfare issues with regard to the standard and the quality of medical care afforded to them. The recommendations and guidelines we came up with was a system to determine specific health care demands for each sport and institution and the suggested qualifications for those providing medical coverage of institutionally-sponsored athletics activities and treatment facilities.

We came up with a narrative to assist the institution in determining a number of qualified health care staff needed to provide appropriate coverage. I've put up appendix A and B, and if you would go to the NATA web site, you can link into this. It's a 60-page document, but on the back of the document there are worksheets you could take and break down to your individual institution just the sports that your institution offers. It would help you work through this. To re-cap, our goal was to insure the health and safety of our student-athletes. We asked that institutions view these as recommendations, as guidelines, but not mandates, to take into consideration the unique needs of their own individual institution. This document is very flexible and can do that. It is also a living document because, as we put this document together, when we went to look at catastrophic injury rates, time loss injury, non time-loss injury treatment areas, there's not a lot of data out there. Where the data wasn't present, the task force would come up with professional consensus for where it is. We are trying to fill in the places where we didn't have adequate data.

The system is based on health care units. It's based on the injury rate index for each individual sport. There is not a lot of good data out there in track and field, women's ice hockey and some other sports. It's based on the catastrophic index. It's based on treatment and injury equivalence. Everybody knows if you have a sprinter with a hamstring injury, they may be out. But, if you have that same injury on another person, an offensive lineman, they may not miss a minute. We need to be able to have adjustments to this, nontraditional, out of season exposures. We found out in the Big Ten a couple of years ago, we were dealing with this nontraditional season where our women's soccer teams were calling each other up and suggesting they meet for a soccer match. They were piling into vans and going and not telling anybody. They would decide the day before to invite another school and have a three-way get together. We were always dealing with issues like this. It's based on your squad size. You can adjust it for travel. You can adjust it for administrative duties, whether it be drug testing, teaching responsibilities.

In February 2000, the NATA Board of Directors unanimously approved these recommendations and guidelines. In June 2000, they also established and gave us money to put together a study to further substantiate the recommendations and guidelines. We did that by trying to get 10 institutions representing each of the following divisions, including the NAIA and the National Junior College Athletic Association. That data is to be used to establish and further substantiate the scientific rationale of this document. It's going to track injury and treatment data from both time-loss and non time-loss injuries. We hope to have it completed by the summer of 2002.

In August of 2000, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports sent a letter to the directors of athletics and university president. They emphasized a consistency between the NCAA and recommendations of philosophies and some of the guidelines. We acknowledged the guidelines were an adequate tool to assist institutions in evaluating health care coverage needs and encouraged each institution's athletics department and administration to consult with sports medicine staff risk management personnel and legal counsel to develop an appropriate sports medicine care and coverage plan.

In September of 2000, an article was published in the NCAA News, written by a member of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. It pointed out that this was a beneficial starting point to assess current levels of sports medicine care. A potential legal liability could exist if an institution failed to develop and implement appropriate medical assistance. Careful consideration of a document will assist in insuring the provision of adequate and high quality health care. This document was introduced in January 2001 to the American Football Coaches Association and they responded favorably to it and have asked to help work with us to bring this to be.

In January 2001, we completed a survey by athletics trainers in Division I, II and III to assess the impact after one year of the document. In January 2001, the AOS, the American Orthopedic Society for Sports Medicine, endorsed these recommendations and guidelines. In April 2001, the American Medical Society for Sports Medicine endorsed the recommendations and guidelines. That group is the primary care team physicians group.

What is coming down the pike that you will hear about or see, is that early this fall, there will be a letter going to the presidents and ADs again to explain or further explain the intent of the document. We're going to continue to present this information in seeking endorsement from governing bodies and key sports medicine organizations including the NCAA, NAIA, the National Junior College Athletic Association, American College of Sports Medicine, etc. We are going to take this document to the Risk Management Association.

We are putting out a call for examples of successful proposals, especially from Divisions II, III, NAIA and junior college schools, to see how people have tried to implement this document. We're developing a group to put together cost analysis surveys and ways to assist universities in ways to implement this document.

The NATA Board of Directors is considering an approach to the NCAA to see if we can't move further along and require that athletics personnel are current in first aid and CPR instead of just recommend that they do. We're going to continue to try and work with the NCAA News and keep the members updated as to what is going on with this document.

That's a little bit of where this document is. We want to make sure we separate these recommendations and guidelines from the changes that are going through our education process that Chad talked about.